American sickness: diagnosis and cure

James A Morone Lawrence R Jacobs
16 October 2007

Most Americans think they live in a nation brimming with opportunity. The story is that we are powerful, rich and open-handed. One penny out of every American dollar goes to charity - no other nation comes close. At the same time, people around the world see a country enthralled by hard-knuckle capitalism, a land of multi-millionaires and hungry children. Which is the real United States? Both. We tolerate enormous differences in wealth and poverty.


A look at Americans' health reveals the astonishing consequences. American girls are born with a life-expectancy that ranks twenty-eighth in the world. Male babies rank thirty-first - in a dead tie with Belize and Dar es Salaam, Tanzania. Among the thirteenth wealthiest countries, the United States ranks last (or nearly last) in almost every way we measure health: infant mortality, low birth-weight, life-expectancy at birth, life-expectancy for infants. The average American boy lives three-and-a-half years less than the average Japanese baby - though the Japanese child is a lot more likely to grow up smoking cigarettes. The American adolescent death-rate is twice as high as, say, England's.

These dismal American averages mask vast differences across our population. A male born in some sections of Washington DC has a life-expectancy forty years lower than a woman born in rural Minnesota. In short, great differences in wealth match up to - put more bluntly, they create - terrible differences in health.

Why do Americans come out so badly in the cross-national health statistics? Why don't our men live as long as those in, say, Croatia? Our health troubles have three interrelated causes: inequality, poverty, and the way we organise our healthcare system.

The costs of failure

The first factor is inequality. American society has become jarringly unequal - the Wall Street Journal reported in October 2007 that inequality levels had reached (and perhaps surpassed) the pre-welfare-state peaks of the 1920s. The wealthiest 1% now earns over 21% of all income, while the entire bottom half earned less than 13% - and the income of that bottom half has been falling since 2000 (see Greg Ip, "Income-Inequality Gap Widens", Wall Street Journal, 12 October 2007).

Lawrence R Jacobs is professor of political studies at the University of Minnesota. His books include (with Theda Skocpol) Inequality and American Democracy: What We Know and What We Need to Learn (Russell Sage Foundation, 2005), and (with Robert Y Shapiro) Politicians Don't Pander: Political Manipulation and the Loss of Democratic Responsiveness (Chicago University Press, 2000)

James A Morone is professor of political science at Brown University. He is a frequent contributor to the American Prospect and the London Review of Books. His books include Hellfire Nation: The Politics of Sin in American History (Yale University Press, 2003)

Lawrence R Jacobs & James A Morone are co-editors of Healthy, Wealthy, and Fair: Health Care for the Good Society (Oxford University Press, 2007). An earlier version of this article appeared in The American Prospect These differences have large health effects. A famous study of the British civil service found that with each rung up the ladder of success people suffered fewer fatal heart-attacks - the clerks and messengers at the bottom were four times more likely to die than the executives at the top. Researchers following up this study came up with a surprising finding that seems to hold up in one nation after another: the higher the levels of inequality - the more rungs on the economic scale, the greater the distance between the richest and the poorest - the worse the nation's health.

Why should this be so in the United States? Falling behind in the race to make ends meet generates stress and physiological harm; the results are depression, hypertension, illnesses and high mortality-rates. In addition, the middle class scramble to get ahead or maintain its standard of living erodes neighbourly feelings, frays our communities and lowers trust in institutions like churches and governments. All of these are factors in other countries. But most industrial nations buffer their citizens against economic uncertainty and lost jobs. In the United States, only the market winners get security (see Godfrey Hodgson, "The next big issue: inequality in America", 13 September 2007)

The second cause of American health problems, relating to the first but distinct from it, is poverty. The alarming health statistics outlined above flow even more directly from the army of poor and near-poor Americans. After all, more than one in ten Americans (almost 33 million) is poor. The census bureau labels 40% of them (13.4 million) "severely poor" - they don't even make it half way to the poverty line. The numbers are worse for minorities; more than a fifth of blacks and Hispanics are poor. And poverty brings all kinds of trouble: like hunger (33 million Americans live with food insecurity) and homelessness (perhaps as many as 3.5 million a year, about 40% of them kids).

Poor neighbourhoods face high crime and poor education. There are few (safe) parks, well-paying jobs, reliable transportation networks or healthcare clinics. Instead, poverty attracts danger - too much alcohol and tobacco, illegal drugs and fast foods. One observer after another has gone off to study poor communities and come back with the same report: the lives of the poor are full of stress and the struggle to get by. Jobs are scarce and pay low. Despite the odds, almost 40% of poor Americans hold jobs - and one in ten (11.5%) manage to work full-time all year round.

People die younger in Harlem than in Bangladesh. Why? It is not what most people think; homicide, drug abuse, and Aids are far down the list. Rather, as the New England Journal of Medicine reports, the leading causes of death in poor black neighbourhoods are "unrelenting stress", "cardiovascular disease", "cancer" and "untreated medical conditions."

The third cause of the Americans' poor comparative health record lies beyond the fundamentals of inequality and poverty. It is rooted in the stubborn American policy dilemma: a yawning gap in health insurance that no other industrial nation would tolerate. The Congressional Budget Office estimates that 47 million people were uninsured in 2006; close to 60 million people had a spell of non-insurance sometime during the year. Perhaps 30 million (a low estimate) are underinsured - their coverage will not be enough for a serious illness. Part of the problem is that workplace coverage is unravelling. Employers continue to offer coverage, but they are shifting more of the costs - premiums, co-payments and coverage limitations - onto the over-burdened shoulders of their workers. Meanwhile, medical costs are rising faster than personal income growth.

Also in openDemocracy on health policy in the United States, our managing editor Grace Davies reviews Michael Moore's Sicko:

"Going to a screening of Michael Moore's Sicko last week, I was in two minds - does the world really need another Moore ‘shockumentary'? What was I going to learn other than that in America, you pay? A bit more than that, as it turns out...." Simple medical care - annual check-ups, screenings, vaccinations, eyeglasses, dentistry - saves lives, improves well-being, and is shockingly uneven. Emergency-room psychiatrists confront attempted suicides with a handful of protocols. Well-insured people get assigned hospital beds; the uninsured get patched up and sent back to the streets. From diagnostic procedures (prostate-screenings, mammograms, and pap-smears) to treatment for asthma, the uninsured get less care; they get it later in their illness episodes; they are roughly three times more likely to have an adverse health outcome. The Institute of Medicine blames gaps in insurance coverage for 17,000 preventable deaths a year.

Even middle-class parents worry about the next medical emergency or, in many cases, the routine trip to the doctor's office. Life without health insurance means constantly measuring aches and fevers against the next payday. Changing jobs brings a new set of anxieties about shifts in medical coverage. Health bills are the largest cause of personal bankruptcy in the United States.

True, no healthcare system elsewhere treats everyone the same way. But disparities in the American system are unusually wide and deep.

The half-steps to change

How can we reverse these trends and begin to build the good society? Conventional wisdom counsels incremental reform. Take one small step at a time and eventually the little advances will add up. A bolder alternative puts aside short-term political considerations, and embraces grand ambitions as the way to mobilise popular sentiment to achieve the hard task of reform. Throughout American political history, the argument goes, the big reforms from both the right and the left began with a small group of believers who push tirelessly against all the odds.

Which path to follow? As the baseball philosopher, Yogi Berra, famously advised, "When you come to a fork in the road, take it." We ought to build incrementally on past successes while pushing bold new proposals and programmes.

Even half-steps - like adding amendments to bipartisan legislation - can add up to something important. When the Ronald Reagan administration of the 1980s was attacking poverty programmes while cutting taxes and running up enormous deficits, Congressman Henry Waxman managed bipartisan support for a series of amendments that (between 1984 and 1990) steadily expanded Medicaid eligibility. The programme grew to cover an additional 5 million children and 500,000 pregnant women.

While Bill Clinton's failure to pass national health insurance got most press attention, his administration quietly enacted the State Children's Health Insurance Program (SCHIPs) for states in 1997. Using federal matching funds as a prod, SCHIPs pushed the states to widen coverage to uninsured children, helping Medicaid reach 20 million children by 2000 and funding non-Medicaid programmes to cover an addition 2 million.

Even further below the national radar-screen, the Robert Wood Johnson Foundation induced state governments to place healthcare clinics directly in schools. Families in under-served neighbourhoods suddenly - and usually for the first time - found it easy for their kids to get into a physician's office. Despite strong initial opposition from the cultural right (they were worried about birth control), teachers, public-health advocates, parents and community organisers have managed to open over 1,200 school centres from Maine to California.

For more information, analysis and advocacy on healthcare issues in the United States, check out the following sources:

Americans for Health Care

Center for American Progress

Center on Budget and Policy Priorities

Institute of Medicine

National Coalition on Health Care

National Committee for Quality Assurance

Physicians for a National Health Program

Robert Wood Johnson Foundation

Urban Institute

World Health Organisation                An earlier version of this article was published in The American Prospect

Reforms beyond medical care improve general living conditions and boost American health. Both Republicans and Democrats have supported tax rebates to low-income workers under an earned income tax-credit programme that has lifted millions out of poverty. The costs of these tax-breaks for low-income families rose from about $2 billion in the mid-1980s to $21 billion by the late 1990s.

These kinds of programmes help. However, small changes will not add up to a system that provides all Americans a decent minimum. Our health problems are too deep. Healthcare is America's trillion-dollar industry. Covering almost 50 million people will be expensive. Making Americans healthy also means addressing the economic insecurity that threatens tens of millions of Americans, forcing middle-class families to work double shifts and the poor to confront hunger and homelessness. George W Bush's "quiet veto" of a bipartisan SCHIP expansion on 3 October 2007 underscores the stubborn political reality: small programmes are just as vulnerable to political attacks as large ones.

Making Americans healthy means casting off the political torpor of this new gilded age and reclaiming a long-standing commitment to our neighbours and communities. Only great aspirations, tirelessly promoted in often unpropitious conditions, will galvanise a new populist politics and leverage our reluctant state.

What works, and is good

There is not much mystery about what works. Other industrial countries (stout capitalists who gave us thinkers like Adam Smith) rely on three familiar paths to good health.

In the first, government plays an important role, though different countries organise it in different ways: family and housing allowances; universal healthcare; generous pensions; tax-credits. The generous welfare states of northern Europe and nations with more modest programmes like France, Germany, and Canada all have poor, middle-class and wealthy populations. However, all these nations frame public polices to make the gaps between groups far less dramatic than they are in the United States.

A second type of policy fosters opportunity. Governments invest in education to expand the supply of skilled labour and help workers help themselves. Lowering the barriers to college education and worker retraining reduces the high premium for skilled labour. In addition, European governments collaborate with business by regularly adjusting the minimum wage and overseeing the negotiations between business and labour.

Third, most wealthy nations maintain taxes. The new global economy was expected to spark dramatic tax cuts as governments competed with each other to create an attractive business climate and lure investment and skilled labour. In Europe and Canada, international pressures did not eviscerate the government's capacity to raise revenues. Domestic support to maintain programmes (and international pressure to limit deficits) barred governments from plunging into tax-cut wars.

In short, America's allies have tried to defend all their citizens from the worst effects of the global economy. The results across the industrial world are powerful: policies that moderate income disparities turn out to be good for your health.

Incremental reforms have not done enough. Some individuals have grown fantastically wealthy; most struggle to make ends meet. The dirty policy secret lies in the health consequences: America's population suffers more illness and dies younger than its counterparts in other comparable countries.

Our call to reform - reflected in many contributions to the book we have co-edited, Healthy, Wealthy, and Fair: Health Care and the Good Society (Oxford University Press, 2007) - is simple. A civilised society should not accept gaping disparities in life and death, health and disability. Americans are too generous and fair-minded a people to tolerate so much preventable suffering. This moral vision undergirds a hard-headed analysis of the rapidly changing global economy that has reshuffled the distribution of money in American society and unsettled the life-circumstances that nurture and protect the health of the country. The solutions are no mystery. Other nations successfully protect their people. So can we.

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